Laparoscopic transhiatal treatment of large epiphrenic esophageal diverticulum

BACKGROUND: Epiphrenic diverticulum is an uncommon disorder of the distal third of the esophagus. We report the case of a 73-year-old woman with a large symptomatic esophageal epiphrenic diverticulum, diffuse nonspecific esophageal dysmotility, and a hiatal hernia. METHODS: Surgery was indicated by the patient's symptoms, the size of the diverticulum (maximum diameter 10 cm), and the associated esophageal motor disorder. Preoperative study included barium swallow, upper gastrointestinal endoscopy, and esophageal manometry. A laparoscopic transhiatal diverticulectomy associated with a Heller myotomy, hiatoplasty, and a Dor's fundoplication was carried out. The overall operative time was 230 minutes. RESULTS: No intraoperative complications occurred. Gastrografin swallow performed on postoperative day 4 did not show any signs of leakage from the staple line. The postoperative hospital stay was 5 days. The patient was readmitted 10 days after discharge complaining of fever and chest pain. A new Gastrografin swallow demonstrated a small leak from the staple line successfully treated with 3 weeks of total enteral nutrition. CONCLUSION: The laparoscopic approach to epiphrenic diverticulum is feasible. Postoperative Gastrografin swallow is not 100% sensitive in detecting small suture-line leaks if a preexisting esophageal motility disorder is present. In case of late postoperative fever and pleural effusion, a suture-line leak should be suspected. Conservative management of the small suture-line leak should be considered as an effective therapeutic option.     

Ultrasound detection of pneumoperitoneum due to colonic diverticulum perforation

Pneumoperitoneum may be shown by abdominal ultrasonography. This case report illustrates the potential value of ultrasound in detecting free intraperitoneal free air in a patient with acute abdominal pain. We outline the ultrasonographic features of pneumoperitoneum and discuss the role of both conventional and cross-sectional imaging modalities in making this diagnosis.     

Zenker’s Diverticula: Feasibility of a Tailored Approach Based on Diverticulum Size

Background  Zenker’s diverticula (ZD) can be treated by transoral diverticulostomy or open surgery (upper esophageal sphincter myotomy and diverticulectomy or diverticulopexy). The aim of this study was to compare the effectiveness of a minimally invasive (group A) versus a traditional open surgical approach (group B) in the treatment of ZD. Material and Methods  Between 1993 and September 2007, 128 ZD patients underwent transoral diverticulostomy (n = 51) or cricopharyngeal myotomy and diverticulectomy or diverticulopexy (n = 77). All patients were evaluated for symptoms using a detailed questionnaire. Manometry recorded upper esophageal sphincter (UES) pressure, relaxations, and intrabolus pharyngeal pressure. The size of the pouch was measured on the barium swallow. The choice of treatment was based on the size of the diverticulum and the patients’ preference. Long-term follow-up data were available for 121/128 (94.5%) patients with a median follow-up of 40 months (interquartile range, 17–83). Results  Mortality was nil. Three patients in group A (5.8%) and ten in group B (13%) had postoperative complications (p = n.s.). Hospital stays were markedly shorter for patients after diverticulostomy (p < 0.01). Postoperative manometry showed a reduction in UES pressure, improved UES relaxation, and lower intrabolus pressure in both groups (p < 0.05). Four patients in the open surgery group (5.2%) complained of severe dysphagia after surgery (three of them required endoscopic dilations). In the transoral diverticulostomy group, 11 patients (21.5%) required additional septal reduction (n = 8) or a surgical myotomy (n = 3) for persistent symptoms (p < 0.01); nine of these 11 patients had a ZD ≤ 3 cm in size. After primary and complementary treatments, symptoms disappeared or improved significantly at long-term follow-up in 93.5% of patients in group A and 96% of those in group B. Conclusion  Diverticulostomy is safe, quick, and effective for most patients with medium-sized ZD, but open surgery offers better long-term results as a primary treatment and should be recommended for younger, healthy patients, especially those with small diverticula. Small ZD may represent a formal contraindication to the transoral approach because an excessively short septum prevents a complete division of the sphincter fibers.     

Double breasting repair of urethral fistula in a patient with perineal abscess secondary to a large urethral stone

We report here a case of urethral fistula managed successfully following incision and drainage for the urethral abscess secondary to a large urethral stone leading to a large diverticulum (another rare condition) by using the technique of double breasting, where we used the redundant urethra and overlying skin.     

Wolff-Parkinson-White Syndrome Associated with a Coronary Sinus Diverticulum: Ablative Surgical Approach

This report concerns a patient with drug refractory supraventricular tachycardia due to the Wolff-Parkinson-White syndrome in association with a coronary sinus diverticulum. Division of the anomalous bypass tract was initially performed by an endocardial approach together with circumferential dissection of the neck of the diverticulum. This procedure failed to ablate the bypass tract that was only successfully divided when the superficial wall of the diverticulum was excised. This case illustrates the close association that exists between an anomalous atrioventricular bypass tract and a coronary sinus diverticulum, and the importance of dividing the superficial wall of the diverticulum as an integral part of the ablative procedure.     

Diagnosis of Coronary Sinus Diverticulum in Wolff-Parkinson-White Syndrome Using Coronary Angiography

The entity of Wolff-Parkinson-White Syndrome and coronary sinus diverticula when the bypass tract is posteroseptal in location has been described recently. The presence of this diverticulum may complicate arrhythmia surgery and could potentially add to the risk of catheter ablation. We describe a case of Wolff-Parkinson-White Syndrome in which the diagnosis of a coronary sinus diverticulum was made preoperatively using late-phase coronary angiography and suggest angiography be considered in patients with posteroseptal bypass tracts prior to surgery or catheter ablation.     

316. Die chirurgische anatomie der leber

Zusammenfassung Von 1960 bis 1986 wurde an unserer Klinik bei 82 Patienten eine Resektion eines Meckelschen Divertikels vorgenommen. Eine Auswertung der Krankheitsverläufe erbrachte folgendes: Die Diagnose ist präoperativ nur selten bekannt (4%), allenfalls im Blutungsfall kommen Angiographie und Szintigraphie zum Einsatz. Heterotopes Gewebe findet sich häufiger bei Komplikationsfällen. Insbesondere bei negativem Appendix-Befund sollte u. E. routinemässig nach dem Divertikel gesucht werden. Die geringe Zahl postoperativer Komplikationen auf der einen und das Komplikationsrisiko eines belassenen Divertikels auf der anderen Seite (Hauptrisikogruppe: Kleinkinder) rechtfertigen die prophylaktische Resektion.

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Frequency and complications in Meckel's diverticulum - retrospective analysis

Summary Between 1960 and 1986, a resection of a Meckel's diverticulum was performed on 82 patients in our hospital. The course of the disease was retrospectively evaluated: The preoperative diagnosis is seldom known (4%) and only in cases of transanal haemorrhage are angiography and scintigraphy useful. Ectopic tissue was found more often in cases with complications. In cases with no inflammatory changes of the appendix, Meckel's diverticulum should be routinely checked. Prophylactic removal of the diverticulum is indicated, as there are few postoperative complications and a risk that the left diverticulum may be the cause of later complications.